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EHD 2"1 07W10 Wal PEPMT App <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> �.1 n <br /> JOB ADDRESS: l tcm ne- 2iyy bp, t/lnlaA Pe, PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is In full force and effect. <br /> License#: �''�7 i 7�) Exp Date: b / <br /> Date: -7 )--a-6 1 l— Contractor. <br /> Signature: C ' GtJ Title: S�D£� <br /> Print Name: I C A/(,' /5, tj 6 o tJ OqO,b <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> i have and will maintain a certificate of consent to self-insure for workers'compensation,as <br /> provided for by Section 3700 of the Labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier. ,4 Eo lu ie. > ( Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California,and <br /> agree that If I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code. I shall forthwith comply with those provisions. <br /> Earp.Date: Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE iS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR iN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, !L �1"e`4 (signature of C-57 licensed authorized representative), <br /> hereby authorize ILrInt"arm) ,to <br /> sign this San Josquln County Well&Boring Permit Application on my behalf. I understand this authortzatkm <br /> Is valid for one year and Is limited to the work pian dated on the front page of this application. <br /> EM28-0s orao so WELL PFPWt APP <br />